Evaluating the effects of moonlight on the vertical flight profiles of three western palaearctic swifts.

Recent studies have suggested the presence of moonlight mediated behaviour in avian aerial insectivores, such as swifts. Here, we use the combined analysis of state-of-the-art activity logger data across three swift species, the common, pallid and alpine swifts, to quantify flight height and activity in responses to moonlight-driven crepuscular and nocturnal light conditions. Our results show a significant response in flight heights to moonlight illuminance for common and pallid swifts, i.e. when moon illuminance increased flight height also increased, while a moonlight-driven response is absent in alpine swifts. We show a weak relationship between night-time illuminance-driven responses and twilight ascending behaviour, suggesting a decoupling of both crepuscular and night-time behaviour. We suggest that swifts optimize their flight behaviour to adapt to favourable night-time light conditions, driven by light-responsive and size-dependent vertical insect stratification and weather conditions.

Heimlich valve orientation error leading to radiographic tension pneumothorax: analysis of an error and a call for education, device redesign and regulatory action.

Medical errors are commonly multifactorial, with adverse clinical consequences often requiring the simultaneous failure of a series of protective layers, termed the Swiss Cheese model. Remedying and preventing future medical errors requires a series of steps, including detection, mitigation of patient harm, disclosure, reporting, root cause analysis, system modification, regulatory action, and engineering and manufacturing reforms. We describe this process applied to two cases of improper orientation of a Heimlich valve in a thoracostomy tube system, resulting in enlargement of an existing pneumothorax and the development of radiographic features of tension pneumothorax. We analyse elements contributing to the occurrence of the error and depict the implementation of reforms within our healthcare system and with regulatory authorities and the manufacturer. We identify features of the Heimlich valve promoting this error and suggest educational, design, and regulatory reforms for enhanced patient safety.

Tracking of Arctic terns Sterna paradisaea reveals longest animal migration.

The study of long-distance migration provides insights into the habits and performance of organisms at the limit of their physical abilities. The Arctic tern Sterna paradisaea is the epitome of such behavior; despite its small size (<125 g), banding recoveries and at-sea surveys suggest that its annual migration from boreal and high Arctic breeding grounds to the Southern Ocean may be the longest seasonal movement of any animal. Our tracking of 11 Arctic terns fitted with miniature (1.4-g) geolocators revealed that these birds do indeed travel huge distances (more than 80,000 km annually for some individuals). As well as confirming the location of the main wintering region, we also identified a previously unknown oceanic stopover area in the North Atlantic used by birds from at least two breeding populations (from Greenland and Iceland). Although birds from the same colony took one of two alternative southbound migration routes following the African or South American coast, all returned on a broadly similar, sigmoidal trajectory, crossing from east to west in the Atlantic in the region of the equatorial Intertropical Convergence Zone. Arctic terns clearly target regions of high marine productivity both as stopover and wintering areas, and exploit prevailing global wind systems to reduce flight costs on long-distance commutes.

Dramatic intraspecific differences in migratory routes, stopover sites and wintering areas, revealed using light-level geolocators.

Migratory divides are contact zones between breeding populations that use divergent migratory routes and have been described in a variety of species. These divides are of major importance to evolution, ecology and conservation but have been identified using limited band recovery data and/or indirect methods. Data from band recoveries and mitochondrial haplotypes suggested that inland and coastal Swainson's thrushes (Catharus ustulatus) form a migratory divide in western North America. We attached light-level geolocators to birds at the edges of this contact zone to provide, to our knowledge, the first direct test of a putative divide using data from individual birds over the entire annual cycle. Coastal thrushes migrated along the west coast to Mexico, Guatemala and Honduras. Some of these birds used multiple wintering sites. Inland thrushes migrated across the Rocky Mountains, through central North America to Columbia and Venezuela. These birds migrated longer distances than coastal birds and performed a loop migration, navigating over the Gulf of Mexico in autumn and around this barrier in spring. These findings support the suggestion that divergent migratory behaviour could contribute to reproductive isolation between migrants, advance our understanding of their non-breeding ecology, and are integral to development of detailed conservation strategies for this group.

Cross-hemisphere migration of a 25 g songbird.

The northern wheatear (Oenanthe oenanthe) is a small (approx. 25 g), insectivorous migrant with one of the largest ranges of any songbird in the world, breeding from the eastern Canadian Arctic across Greenland, Eurasia and into Alaska (AK). However, there is no evidence that breeding populations in the New World have established overwintering sites in the Western Hemisphere. Using light-level geolocators, we demonstrate that individuals from these New World regions overwinter in northern sub-Sahara Africa, with Alaskan birds travelling approximately 14 500 km each way and an eastern Canadian Arctic bird crossing a wide stretch of the North Atlantic (approx. 3500 km). These remarkable journeys, particularly for a bird of this size, last between one to three months depending on breeding location and season (autumn/spring) and result in mean overall migration speeds of up to 290 km d(-1). Stable-hydrogen isotope analysis of winter-grown feathers sampled from breeding birds generally support the notion that Alaskan birds overwinter primarily in eastern Africa and eastern Canadian Arctic birds overwinter mainly in western Africa. Our results provide the first evidence of a migratory songbird capable of linking African ecosystems of the Old World with Arctic regions of the New World.

Evaluating the role of postoperative prophylactic antibiotics in primary and secondary breast augmentation: a retrospective review.

BACKGROUND: The use of postoperative prophylactic antibiotics following augmentation mammaplasty remains a controversial topic, with many surgeons opting for extended prophylaxis. OBJECTIVES: The authors evaluate the role of postoperative prophylactic antibiotics in both primary and secondary cosmetic breast augmentation. METHODS: A five-year retrospective chart review was performed on all patients undergoing cosmetic breast augmentation at a single institution from January 2005 to December 2009. The four attending physicians in this study utilized similar perioperative protocol and implant materials. Patients were divided into two cohorts: those who had received three days of postoperative antibiotics (primarily cephalosporins) and those who had not. End points of particular interest included infection, capsular contracture (CC), and local wound complications. The mean follow-up time was 3.8 years. RESULTS: A total of 605 implants were included over the five-year study period. The overall infection rate was 0.66%. For primary augmentation, 493 implants were studied, with 52% of those patients having received postoperative antibiotics. There was no statistically significant reduction in infection, CC, or total complication rate for those receiving postoperative antibiotics. Similarly, 112 implants were studied for secondary augmentation, and again, postoperative antibiotics were not associated with a reduction in complications. CONCLUSIONS: The data suggest that there was no reduction in the overall rate of total complications, infection, or CC with postoperative prophylactic antibiotics for either primary or secondary cosmetic breast augmentation. This study provides Level 3 evidence in support of discontinuing prophylactic postoperative antibiotics following cosmetic breast augmentation.

Warren B. Davis and the Birth of Plastic Surgery in Philadelphia: A Historical Vignette.

The field of plastic surgery, formally organized in 1931 with the founding of the American Society of Plastic and Reconstructive Surgery, was shaped in many ways by a small practice of Philadelphia physicians. At the center of the practice was Warren B. Davis, a Philadelphia otolaryngologist and plastics pioneer whose innovations in cleft palate surgery would lead to significant improvements in functional and cosmetic outcomes in his time. In addition to his own innovations, Davis was responsible for the training of John Reese, the inventor of the Reese dermatome that changed the face of burn medicine during World War II. Aside from his contributions to surgery and the founding of the American Society of Plastic and Reconstructive Surgery, Dr. Davis was also the founder and first editor of the Plastic and Reconstructive Surgery journal which to this day is the premiere, authoritative journal of plastic surgery. Lastly, Dr. Davis established a plastic surgical practice, now Jefferson Plastic Surgery. Unique in its longevity, this practice would continue to shape the field of plastic surgery and continues to improve lives today-109 years after its founding in 1913.

Effects of post-breeding moult and energetic condition on timing of songbird migration into the tropics.

Each autumn billions of songbirds migrate between the temperate zone and tropics, but little is known about how events on the breeding grounds affect migration to the tropics. Here, we use light level geolocators to track the autumn migration of wood thrushes Hylocichla mustelina and test for the first time if late moult and poor physiological condition prior to migration delays arrival on the winter territory. Late nesting thrushes postponed feather moult, and birds with less advanced moult in August were significantly farther north on 10 October while en route to the tropics. Individuals in relatively poor energetic condition in August (high ß-Hydroxybutyrate, low triglyceride, narrow feather growth bars) passed into the tropics significantly later in October. However, late moult and poor pre-migratory condition did not result in late arrival on the winter territory because stopover duration was highly variable late in migration. Although carry-over effects from the winter territory to spring migration may be strong in migratory songbirds, our study suggests that high reproductive effort late in the season does not impose time constraints that delay winter territory acquisition.

Great flights by great snipes: long and fast non-stop migration over benign habitats.

Migratory land birds perform extreme endurance flights when crossing ecological barriers, such as deserts, oceans and ice-caps. When travelling over benign areas, birds are expected to migrate by shorter flight steps, since carrying the heavy fuel loads needed for long non-stop flights comes at considerable cost. Here, we show that great snipes Gallinago media made long and fast non-stop flights (4300-6800 km in 48-96 h), not only over deserts and seas but also over wide areas of suitable habitats, which represents a previously unknown migration strategy among land birds. Furthermore, the great snipes achieved very high ground speeds (15-27 m s(-1)), which was not an effect of strong tailwind support, and we know of no other animal that travels this rapidly over such a long distance. Our results demonstrate that some migratory birds are prepared to accept extreme costs of strenuous exercise and large fuel loads, even when stopover sites are available along the route and there is little tailwind assistance. A strategy of storing a lot of energy before departure, even if migration is over benign habitats, may be advantageous owing to differential conditions of fuel deposition, predation or infection risk along the migration route.

Paraspinous muscle flap reconstruction of complex midline back wounds: Risk factors and postreconstruction complications.

With increasingly complex spine surgeries now being performed on a more comorbid patient population, the reconstruction of midline back wounds from these procedures is becoming a frequent dilemma encountered by plastic surgery. The purpose of this study is to examine the effect of various preoperative risk factors on postoperative wound healing complications after paraspinous muscle flap reconstruction of midline back defects. An Institutional Review Board-approved, 11-year, retrospective, office and hospital chart review was conducted. All adult patients who underwent paraspinous muscle flap reconstruction during the study period were included. There were 92 patients in the study, representing the largest reported series to-date for the paraspinous muscle flap procedure. Mean follow-up was 120 days. Several wound-healing risk factors were present in this patient population: 72% were malnourished, 41% had hypertension, 37% were obese, 34% had a history of smoking, 32% had diabetes, 16% were on chronic steroids, 14% had a history of more than 2 previous spine surgeries, and 9% had a history of radiation to the wound area. Factors significantly (P < 0.05) associated with postreconstruction wound complications included history of traumatic spine injury, prereconstruction hardware removal, a history of more than 2 spine surgeries, hypertension, and lumbar wound location. This patient population possesses multiple comorbidities making complex wound healing difficult. Several specific risk factors are associated with an increased rate of postreconstruction wound complications after paraspinous muscle flaps. The paraspinous muscle flap remains an important tool for spinal wound reconstruction in the reconstructive surgeon's armamentarium.

The Psychology of Shame: A Resilience Seminar for Medical Students.

Introduction: Shame is a powerful emotion that can cause emotional distress, impaired empathy, social isolation, and unprofessional behavior in medical learners. However, interventions to help learners constructively engage with shame are rare. This module educated medical students about shame, guided them through an exploration of their shame experiences, and facilitated development of shame resilience. Methods: In this 2-hour workshop, clinical-year medical students were guided through the psychology of shame through didactic slides. Next, a small panel of volunteer students, recruited and coached prior to the workshop, shared reflections on the content, including their shame experiences during medical school. This was followed by didactic slides outlining strategies to promote shame resilience. Participants then broke into faculty-led small groups to discuss session content. The module included a small-group facilitator guide for leading discussions on shame, didactic slides, discussion prompts, an evaluation tool, and a film entitled The Shame Conversation that was created after the initial workshop. Results: A retrospective pre/postsurvey revealed statistically significant increases in: (1) importance ascribed to identifying shame in one's self or colleagues, (2) confidence in one's ability to recover from a shame reaction, and (3) comfort in reaching out to others when shame occurs. Analysis of open-ended questions showed that students felt the seminar would enhance future resilience by helping them identify and normalize shame, distinguish shame from guilt, and reach out to others for help. Discussion: This workshop appears to prepare students to more constructively engage with shame when it occurs in medical training.

Addressing the Elephant in the Room: A Shame Resilience Seminar for Medical Students.

PROBLEM: Medical schools face the challenge of developing efficacious resources to promote well-being and foster resilience in students. The authors developed, implemented, and evaluated a shame resilience seminar for second-year clerkship medical students. APPROACH: In February 2018, the authors conducted a 2.5-hour seminar (part of a longitudinal series) about shame, a common and potentially damaging emotion. The seminar consisted of a large-group session to introduce the psychology of shame, during which speakers shared their personal experiences with the emotion. Next, a small-group session allowed students to discuss their reactions to the large-group content in a safe and familiar environment. Before the seminar, faculty development was provided to small-group leaders (upper-level medical students and faculty) to increase their comfort leading discussions about shame. Students completed a pre/post retrospective survey immediately following the seminar. OUTCOMES: The authors found statistically significant increases in students' confidence in identifying shame and differentiating it from guilt; in their attitudes regarding the importance of identifying shame reactions in themselves and others; and in their willingness to reach out to others during a shame reaction. Surveys of group leaders revealed no reports of significant student distress during or after the seminar. NEXT STEPS: This seminar represents a reproducible means of promoting shame resilience in medical students. The speakers' personal shame experiences and the safety of the small groups for discussions about shame were central to the seminar's apparent success. Next steps include developing an empirically derived, longitudinal shame resilience curriculum spanning the medical school years.

Superior pedicle reduction mammaplasty.

The superior pedicle reduction mammaplasty allows most premenopausal women to maintain lactational capabilities and nipple sensation. It is a relatively simple breast reduction technique which, according to the author, achieves an aesthetically pleasing breast shape with no "bottoming out" and a high level of patient satisfaction.

An Asthma Protocol Improved Adherence to Evidence-Based Guidelines for Pediatric Subjects With Status Asthmaticus in the Emergency Department.

BACKGROUND: In our institution's pediatric emergency department, adherence to evidence-based asthma guidelines was noted to be suboptimal for patients with asthma exacerbations. We hypothesized that an evidence-based asthma protocol would improve time to treatment and adherence to National Institutes of Health guidelines for patients presenting to the emergency department with status asthmaticus. METHODS: Subjects at our institution were retrospectively identified through an electronic medical record search following institutional review board approval. The asthma protocol was initiated in February 2012. All pediatric subjects who received continuous albuterol in the emergency department before (February 26, 2009, to February 22, 2012, n = 193) and after (February 23, 2012, to December 31, 2012, n = 68) protocol initiation were analyzed. The post-protocol data were collected as part of routine quality assurance monitoring with a target of 60 post-protocol subjects. Subjects were identified at the end of each month, which resulted in a total of 68 subjects being included. Primary outcomes measured included time to initial treatment with inhaled bronchodilator therapy, time to treatment with systemic corticosteroids, and total number of ipratropium bromide treatments delivered. RESULTS: Two-hundred sixty-one subjects (7.1 ± 4.6 y of age, 66% male) were included. Demographics were similar in the pre- and post-protocol groups. Compared with the pre-protocol group, more subjects in the post-protocol group received bronchodilators within 30 min (60% vs 77%, P = .02), at least one dose of ipratropium bromide (55% vs 87%, P < .001), 3 doses of ipratropium bromide (14% vs 54%, P < .001), and corticosteroids within 60 min (62% vs 77%, P = .04). There were no statistically significant differences between the pre- and post-protocol cohorts in the mean time to first bronchodilator treatment (32 ± 41 vs 26 ± 52 min, P = .34), mean time to corticosteroid administration (74 ± 68 vs 54 ± 63 min, P = .06), or mean emergency department length of stay (342 ± 143 vs 364 ± 183 min, P = .31). CONCLUSIONS: An asthma protocol resulted in improved adherence to National Institutes of Health guidelines in children with status asthmaticus and improved efficiency in the administration of rescue bronchodilator and systemic corticosteroid therapy.

A Continent-Wide Migratory Divide in North American Breeding Barn Swallows (Hirundo rustica).

Populations of most North American aerial insectivores have undergone steep population declines over the past 40 years but the relative importance of factors operating on breeding, wintering, or stopover sites remains unknown. We used archival light-level geolocators to track the phenology, movements and winter locations of barn swallows (Hirdundo rustica; n = 27) from populations across North America to determine their migratory connectivity. We identified an east-west continental migratory divide for barn swallows with birds from western regions (Washington State, USA (n = 8) and Saskatchewan, Canada (n = 5)) traveling shorter distances to wintering areas ranging from Oregon to northern Colombia than eastern populations (Ontario (n = 3) and New Brunswick (n = 10), Canada) which wintered in South America south of the Amazon basin. A single swallow from a stable population in Alabama shared a similar migration route to eastern barn swallows but wintered farther north in northeast Brazil indicating a potential leap frog pattern migratory among eastern birds. Six of 9 (67%) birds from the two eastern populations and Alabama underwent a loop migration west of fall migration routes including around the Gulf of Mexico travelling a mean of 2,224 km and 722 km longer on spring migration, respectively. Longer migration distances, including the requirement to cross the Caribbean Sea and Gulf of Mexico and subsequent shorter sedentary wintering periods, may exacerbate declines for populations breeding in northeastern North America.

An exception to the rule: carry-over effects do not accumulate in a long-distance migratory bird.

Recent years have seen a growing consensus that events during one part of an animal's annual cycle can detrimentally affect its future fitness. Notably, migratory species have been shown to commonly display such carry-over effects, facing severe time constraints and physiological stresses that can influence events across seasons. However, to date, no study has examined a full annual cycle to determine when these carry-over effects arise and how long they persist within and across years. Understanding when carry-over effects are created and how they persist is critical to identifying those periods and geographic locations that constrain the annual cycle of a population and determining how selection is acting upon individuals throughout the entire year. Using three consecutive years of migration tracks and four consecutive years of breeding success data, we tested whether carry-over effects in the form of timing deviations during one migratory segment of the annual cycle represent fitness costs that persist or accumulate across the annual cycle for a long-distance migratory bird, the Hudsonian godwit, Limosa haemastica. We found that individual godwits could migrate progressively later than population mean over the course of an entire migration period, especially southbound migration, but that these deviations did not accumulate across the entire year and were not consistently detected among individuals across years. Furthermore, neither the accumulation of lateness during previous portions of the annual cycle nor arrival date at the breeding grounds resulted in individuals suffering reductions in their breeding success or survival. Given their extreme life history, such a lack of carry-over effects suggests that strong selection exists on godwits at each stage of the annual cycle and that carry-over effects may not be able to persist in such a system, but also emphasizes that high-quality stopover and wintering sites are critical to the maintenance of long-distance migratory populations.

Migration routes and staging areas of trans-Saharan Turtle Doves appraised from light-level geolocators.

The identification of migration routes, wintering grounds and stopover sites are crucial issues for the understanding of the Palearctic-African bird migration system as well as for the development of relevant conservation strategies for trans-Saharan migrants. Using miniaturized light-level geolocators we report a comprehensive and detailed year round track of a granivorous trans-Saharan migrant, the European Turtle Dove (Streptopelia turtur). From five recovered loggers, our data provide new insights on migratory journeys and winter destinations of Turtle Doves originating from a breeding population in Western France. Data confirm that Turtle Doves wintered in West Africa. The main wintering area encompassed Western Mali, the Inner Delta Niger and the Malian/Mauritanian border. Some individuals also extended their wintering ranges over North Guinea, North-West of Burkina Faso and the Ivory-Coast. Our results reveal that all individuals did not spend the winter period at a single location; some of them experienced a clear eastward shift of several hundred kilometres. We also found evidence for a loop migration pattern, with a post-breeding migration flyway lying west of the spring route. Finally, we found that on their way back to breeding grounds Turtle Doves needed to refuel after crossing the Sahara desert. Contrary to previous suggestions, our data reveal that birds used stopover sites for several weeks, presumably in Morocco and North Algeria. This later finding is a crucial issue for future conservation strategies because environmental conditions on these staging areas might play a pivotal role in population dynamics of this declining species.

Migration routes and strategies in a highly aerial migrant, the common swift Apus apus, revealed by light-level geolocators.

The tracking of small avian migrants has only recently become possible by the use of small light-level geolocators, allowing the reconstruction of whole migration routes, as well as timing and speed of migration and identification of wintering areas. Such information is crucial for evaluating theories about migration strategies and pinpointing critical areas for migrants of potential conservation value. Here we report data about migration in the common swift, a highly aerial and long-distance migrating species for which only limited information based on ringing recoveries about migration routes and wintering areas is available. Six individuals were successfully tracked throughout a complete migration cycle from Sweden to Africa and back. The autumn migration followed a similar route in all individuals, with an initial southward movement through Europe followed by a more southwest-bound course through Western Sahara to Sub-Saharan stopovers, before a south-eastward approach to the final wintering areas in the Congo basin. After approximately six months at wintering sites, which shifted in three of the individuals, spring migration commenced in late April towards a restricted stopover area in West Africa in all but one individual that migrated directly towards north from the wintering area. The first part of spring migration involved a crossing of the Gulf of Guinea in those individuals that visited West Africa. Spring migration was generally wind assisted within Africa, while through Europe variable or head winds were encountered. The average detour at about 50% could be explained by the existence of key feeding sites and wind patterns. The common swift adopts a mixed fly-and-forage strategy, facilitated by its favourable aerodynamic design allowing for efficient use of fuel. This strategy allowed swifts to reach average migration speeds well above 300 km/day in spring, which is higher than possible for similar sized passerines. This study demonstrates that new technology may drastically change our views about migration routes and strategies in small birds, as well as showing the unexpected use of very limited geographical areas during migration that may have important consequences for conservation strategies for migrants.

Reconstruction of complex posterior cervical spine wounds using the paraspinous muscle flap.

BACKGROUND: The paraspinous muscle flap is often overlooked for use in cervical wounds, as surgeons cite the decreased size and mobility of the muscles in the cervical region. The purpose of this article is to introduce the paraspinous muscle flap technique for reconstruction of cervical spine wounds. METHODS: An 11-year, single-institution, retrospective chart review was performed on 14 consecutive patients from 1996 to 2007. All patients underwent paraspinous muscle flap surgery to provide soft-tissue coverage of the cervical spine following wound healing complications resulting in exposed hardware or bone. Variables of interest included demographics, comorbidities, and postreconstruction wound healing complications. RESULTS: The overall complication rate after paraspinous muscle flap surgery was low [two of 14 (14 percent)] and consisted of two minor wound infections. There was no postreconstruction seroma, a well-known complication of the trapezius muscle flap, which is often thought of as the first-line option for posterior cervical soft-tissue reconstruction. CONCLUSION: The paraspinous muscle flap is an expeditious and reliable solution to complex cervical spine wounds. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.(Figure is included in full-text article.).